In less than a decade, online social networks have become a prominent and powerful extension of social interactions throughout our culture. Through tools like blogs, Facebook, and Twitter, we keep in touch with friends, make new friends, do business, and gain new knowledge.

Health care professionals do not exist in isolation from online social networks. These new online tools offer the same social, informational, and professional benefits to doctors, nurses, and pharmacists as they do to executives, students, merchants, and retirees. Since so much of health care relies on effective and professional communication among health care professionals and between them and their patients, a communication tool like online social networks has significant potential to affect the effective delivery of health care. Preliminary to studying how the use of online social networks may affect the practice and outcomes of health care, it is important to understand how and how much health care professionals are adopting and using online social networks to support their professional practice. Given the sensitive, high-stakes nature of health care, it is also important to understand the ethical dimensions of online social network use among health care professionals.

Online Social Networks: Defining the Field

The “backbone” of online social networks is the connected collection of user profiles (Boyd & Ellison, 2008). Such profiles usually include user names, photos, and basic demographic information. Online social networks generally include information about connections between members. That information may reside in explicitly declared links, like unidirectional “Like” or “Follower” links or bidirectional “Friend” links (Boyd & Ellison, 2008). Health care providers may interact with patients and with each other on any established online social networking site. Health care providers may turn to health social networks specializing in health issues. They may focus their online activity even more narrowly in online social networks like Sermo.com, membership to which is open exclusively to physicians.

Inquiry into health care provider use of online social networks need not be confined to platforms like Facebook or Sermo. While such platforms dedicated to social networking create an easy point of entry, standardized format, and accessible audience for most casual Internet users, some health care professionals may create their own online social networks through their own blogs, wikis, and other social media. For example, several nurses may create independent blogs but over time find each other’s websites. They may include each other on their blogrolls, comment on each other’s blogs, and write blog posts responding to items they read on each other’s blogs. This nurse “blogosphere” may exist on several different platforms (Blogger, Tumblr, WordPress, etc.), have no formal leadership or organization, follow no business model, and offer no standardized format or features, but it would still constitute an online social network. Its “backbone” of user profiles may be much less well defined than the profile/friend structure of platforms like Facebook, but a blogosphere still offers a clearly definable network of social interactions supported by online technology.

Professional–Patient Use

Patients are turning increasingly toward the Internet for health information (Fox & Jones, 2009). No longer the “sole custodian[s] of medical data” (Eysenbach, 2008), health care professionals are increasingly “one of many input sources” (Swan, 2009). Some health care providers are responding to this shift in patient demand: as of January 2011, 906 U.S. hospitals (less than 20% of all U.S. hospitals) had established 3,087 social networking sites (Bennett, 2011). 170 Canadian hospitals (12% of total) have been found to be using social media (Fuller, 2011). Social media adoption rates among European hospitals vary, with around 45% of Norwegian and Swedish hospitals using LinkedIn, but 22% hospital adoption of Facebook in Norway compared to 0% in Sweden. The percentage of German hospitals using online social networks is in the single digits, while adoption in the United Kingdom ranges from 16% for Facebook, 21% for Twitter, and 41% for LinkedIn (Engelen, 2011). Australia’s hospitals are lagging 12 to 18 months behind the U.S. in social media adoption (Cadogan, 2011).

Medical schools are also catching up with adoption of the Web and social networking sites. As of March 31, 2010, 100% of U.S. medical schools had websites. 95% of U.S. medical schools had some sort of Facebook presence: a quarter had official school pages, over 70% had student groups, and more than half had alumni groups on the social networking site. Just over 10% had Twitter accounts (Kind, Genrich, Sodhi, & K. C. Chretien, 2010).

Creating a social media presence does not mean hospitals and other institutions are using them effectively to promote interaction with patients. A marketing study of 120 American hospitals selected at random found all had Facebook pages, but less than 40% posted content to those pages daily, 25% posted twice a week, 25% posted once a month, and 5% had posted nothing (Dolan, 2011). Any discussion of health care providers’ use of online social networks requires remaining mindful that effective use of online social networks requires being social—i.e., being present, producing content, and interacting, not just creating a static electronic brochure.

Patients are seeking information to supplement, not replace, the advice of health care professionals. Overwhelming majorities say professional sources are more helpful in providing accurate medical diagnoses and information about prescription drugs; strong majorities also favor professional sources for information about alternative treatments and recommendations for doctors, specialists, or medical facilities (Fox, 2011). Smaller majorities prefer non-professional sources for emotional support and quick remedies to everyday health issues (Fox, 2011). This split suggests that patients may be receptive to informational support from health care professionals in online social networks but that professionals may want to extend their professional emotional reserve to the online realm and leave laypeople the room they value to provide each other emotional support.

Health care professionals have been able to enter patient health social networks to recruit participants for medical trials. As part of its multi-platform social media strategy during the 2009 H1N1 outbreak the CDC monitored and responded to social network conversations to provide the public with accurate disease and treatment information (Keckley & Hoffman, 2010).

While engaging patients in the online forums they are adopting has the capacity to build effective provider-patient relationships, the health care industry lags in adoption of social media in part due to lack of a clear business model. Online social network activities require time and effort; compensating the physician and the facility for such engagement, from information systems development and maintenance to the actual medical information shared by practitioners, is complicated. Charging patients by the Tweet is problematic in a realm where users are accustomed to free-flowing, unmetered exchanges. Advertising is restricted by professional guidelines and regulations (Keckley & Hoffman, 2010), thus hindering another possible revenue source to make social media efforts pay for themselves.

Health care professionals may find support for an online social-networking business case in the marketing potential of such online tools. Online social networks offer health care professionals the ability to disseminate information quickly, broadly, and at almost no cost. They allow providers to cheaply advertise health-related seminars and community activities. From a pure marketing standpoint, using online social networks to interact with patients sends a message to return and potential “customers” that the providers and their hospital or clinic are cutting edge businesses (Tariman, 2010). Engaging in social media may also be “essential” for institutions and practitioners to combat misinformation that patients and others will spread via those same channels (Pho, 2011a). High-quality physician blogs like KevinMD humanize the healthcare industry as a whole, giving physicians’ perspectives and offering popularly accessible explanations of medical decisions (Bhargava, 2009).

Professional–Professional Use

Health care professionals can also use online social networking to obtain information and other support for themselves. Professionals are using these online resources, especially younger professionals (Guseh, R. W. Brendel, & D. H. Brendel, 2009). Roughly one in six U.S. physicians have created accounts on Sermo.com (Bureau of Labor Statistics, 2009; “Introduction | Sermo.com,” 2011). Ozmosis and SocialMD offer similar “walled (and safe) communities for physicians to share opinions and interact in a guarded environment” (Bhargava, 2009). 65% of nurses say they plan to use online social networks for professional purposes (Keckley & Hoffman, 2010).

Health care professionals, like professionals in other fields, have found blogs useful as public document repositories, discussion space, and opportunities to expand professional networks and knowledge base (Thielst, 2007). Such blogs become part of the literature and public face of the profession, informing and reflecting on the medical community as a whole (Lagu, Kaufman, Asch, & Armstrong, 2008). Less public, members-only social networks for physicians may support more valuable sharing of specific medical knowledge and support. Professional online social networks Sermo, Ozmosis, and radRounds allow members to share cases for community discussion and collaboration (Keckley & Hoffman, 2010).

Ethical Issues

Doctor-patient interaction online remains relatively rare. Only 5% of adults report receiving information, care, or support from health professionals online (Fox, 2011), a number no higher than the number of adults who reported exchanging e-mails with their doctors in 2008 (Cohen, 2009). Such interaction is stymied not by an absence of health care professionals in online social networks but by ethical concerns. In 2009, 60% of U.S. physicians said they were already using online social networks or were interested in doing so (Darves, 2010). A survey of medical residents and fellows at one French facility in fall 2009 found 73% of respondents had Facebook profiles, with 99% of those including the user’s real name, 97% including birthdates, and 91% including a personal photo. 85% of responding medical professionals said they would automatically decline “friend” requests from patients, and 76% expressed concern that a patient discovering a physician’s Facebook account and gaining access to the content would affect the doctor-patient relationship (Moubarak, Guiot, Y. Benhamou, A. Benhamou, & Hariri, 2011). Another study found more than 80% of University of Florida medical students and residents included personally identifiable information in their Facebook accounts, and only 33% of those users imposed privacy protections on that information (Thompson et al., 2008).

A fundamental tension exists between establishing appropriate boundaries (Luo, 2009) and promoting education and empowerment, a problem addressed by developing “a more sophisticated awareness of privacy and engagement within online communities” (Lewis, Goldman, Bennett, Shine Dyer, & Kolmes, 2011). That understanding of engagement may require simply applying the common sense of face-to-face workplace communication: treat the online social network as a public space at the hospital, and make the publicity explicit to patients who may share that space to give them a sense of what personal matters they should address offline (Giurleo, 2011a; Sydney, 2007). Such public prudence may not differ significantly from the professional ethics doctors have wrestled with in social situations for generations; however, the stakes of maintaining that professionalism are arguably higher in the online realm, where indiscretions can cause damage much more quickly across a much larger social network (Jain, 2009). Ethical professional use of social media also requires constant compassion, with a concerted awareness that the avatars and text with which professionals interact are still real people (Giurleo, 2011b), an awareness that may too easily be lost in online realms that convey less social presence.

Ethical demands may differ among different health care fields. For example, psychotherapists use transference, in which patients experience the psychotherapist in ways similar to their connections with people from their past, to help patients work through their problems. Psychotherapists avoid self-disclosure and maintain professional boundaries to avoid hindering that process. Self-disclosure via social networks may directly impact treatment (Luo, 2009). Because of the nature of their work, psychiatrists who engage in public activities on blogs or Facebook may draw unwelcome attention from emotionally unstable or dependent individuals (Perez-Garcia, 1998). Direct communication and the face-to-face process of narrating their own stories are part of treatment; accessing information about therapists online may short-circuit those processes (Yan, 2009).

On the other hand, psychiatrists may find uniquely valuable information about their patients’ thoughts, emotions, and relationships by using Web searches and social networking sites to incorporate Internet habits into their history-taking (Perez-Garcia, 2010). Health care providers may be able to use online information to verify patient information, especially in mental health situations where patients may be prone to falsehood (Luo, 2009). Acting on false information supplied by patients may lead health care providers to deliver incorrect or harmful treatments; however, online information may be just as prone to inaccuracy and requires active efforts at verification (Hughes, 2009). The APA Ethics Committee has ruled that using the Internet to gather information about a patient is ethical “only in the interests of promoting the patient’s care and well-being and never to satisfy the curiosity or other needs of the psychiatrist,” but another expert contends that Googling patients without their knowledge, even in the interest of providing care, violates patient autonomy and dignity (Yan, 2009).

The problem of unintended disclosure on online social networks may affect patients as well as providers. For example, a physician discovered via Facebook photos that a patient who had denied smoking was indeed a smoker (Guseh et al., 2009). Such unintended disclosure may provide the physician information that may affect recommended treatment; however, if included on medical records, that unintended disclosure could also cause the patient to face higher medical insurance premiums (Chin, 2010).

To avoid ethical pitfalls and harm to patient care, some professionals may also adopt the position that as social and recreational spaces, popular online social networks like Facebook are as inappropriate a space for professional–patient interaction as the local bar; such professionals may thus declare online social networks totally off limits (Darves, 2010; Tariman, 2010). Others recommend very cautious guidelines for online social network engagement, with a first principle of “friending” patients being don’t (Guseh et al., 2009). However, one may question whether health care providers restricting their online social network content to purely professional material will miss out on the social utility of such we tools and whether limiting disclosure on Facebook and personal blogs will make any meaningful contribution to professional privacy when vast amounts of information about health care professionals is already available on other sites outside of their control (Holm, 2009). While certain one-to-one interactions like “friending” on Facebook may complicate professional detachment, forthright engagement with the general public in health care provider blogs and other social networking tools may help put a human face on the industry and provide consumers with a better understanding of health care (Bhargava, 2009). Medicine and law are still catching up with technology, so to avoid running afoul of HIPAA and other rules, practitioners generally avoid blogging about patients, even though discussions of certain challenging cases could be greatly informative for the general public (Darves, 2010). Despite ethical complications—or perhaps because of them, practitioner blogs may be the most logical venue for discussion of ethical and practical guidelines for engaging patients and fellow professionals in social media settings to improve health care delivery. One might even argue that practitioners have a professional, ethical obligation to use the blogs and other social networking tools by which misinformation might spread to combat that misinformation by helping patients find reputable health data (Pho, 2011b).

Awareness of privacy issues online is not universal. A 2006 sampling of medical blog content found 33% providing first and last name of authors and 16% providing sufficient identifying information (Lagu et al., 2008). 16% included positive comments about patients; 18% included negative comments about patients. Blogging allows some popular health care professionals to disseminate good health information to the masses (Darves, 2010), but that same channel can carry incorrect and harmful information just as quickly. To avoid harm and personal liability, health care professionals engaging in blogging appear to be developing voluntary “self-regulation regarding patient privacy, transparency, anonymity, and patient respect” (Kruglyak, 2006; Lagu et al., 2008).

Such self-regulation appears to rise with experience and training: multiple investigations find younger medical students and recent medical school graduates frequently exhibiting unprofessional behavior in online social networks, although concerns in this area seem to arise as much from injudicious posting of their own personal information and evidence of behavior outside healthcare settings that might impinge on their and their schools’ or employers’ reputations as from actual improper healthcare practice or improper direct interaction with patients or other professionals (Cain, Scott, & Akers, 2009; K. C. Chretien, Greysen, J.-P. Chretien, & Kind, 2009; MacDonald, Sohn, & Ellis, 2010; Thompson et al., 2008). Institutions like Harvard Medical School and Drexel University College of Medicine already caution students about the potential unintended professional consequences of injudicious personal disclosures on social networking sites (Jain, 2009). However, as of March 31, 2010, while nearly 97% of U.S. medical schools had posted student guidelines on publicly available websites, only 10% had published conduct policies specific to social media (Kind et al., 2010). Given that prohibiting online social network use is unlikely to stop the widespread adoption and use of these tools by health care professionals, it seems more fruitful to follow to route recommended for using e-mail in health care: proactively defining boundaries, improving user knowledge, and developing practical guidelines centered around patient privacy and trust (Chin, 2010). A similar route in online social networking—developing training in privacy, identity protection, and e-professionalism (Mattingly, Cain, & Fink, 2010; Thompson et al., 2008)—seems a more mature route (van den Broek, 2010) that will trains medical students to develop the professionalism necessary to navigate difficult situations rather than simply avoiding them. Such an approach that addresses the challenges of professionalism online would then allow practitioners, professional organizations, and health care businesses to harness online social networks for advancement of the profession

Directions

Adoption of online social networks is unlikely to subside, especially as mobile tools accelerate the blurring of boundaries between online and offline social networks. That adoption process may be slower among health care professionals in their work than among other users in other professions, due to the sensitive and literally life-or-death nature of health care and the professional and ethical considerations that arise therefrom. The health care profession is moving more cautiously into this realm of electronic communication just as it has moved more cautiously from paper to electronic medical records. An inappropriate use of new tools in health care could cause enormous harm. But just as with electronic medical records, the appropriate use of online social networks to communicate with patients and fellow professionals could greatly improve the delivery of health care.

Understanding the current state of online social network use by health care professionals, we can proceed to investigating those potential improvements. Some evidence already exists that patients can find online interaction with doctors satisfactory (Cohen, 2009). Research should further investigate the capacity of online social networks to improve patient perceptions of health care and well-being. Similarly, it will be valuable to determine the satisfaction health care providers obtain in using such online tools, as well as potential professional and organizational benefits such as better workflow, cost savings, acquisition of expertise, and development of and engagement with professional organizations.

While more complicated to quantify, research should also investigate whether health care professionals’ engagement results in better health outcomes. Does advice given online affect the likelihood of patients adopting and sticking with prescribed health behaviors? Does online engagement increase patients’ likelihood to consult with physicians on subsequent health issues? Could online interaction lead to a reduction in face-to-face visits that might in turn lead to health care providers missing certain health indicators that would be obvious in a physical meeting? Answers to all of these question will be of keen interest to providers and patients alike.

Parallel to this course of health investigation should run a line of ethical investigation. As we investigate the impacts of online social networks on provider-patient relationships, we should engage providers and patients in conversations about their expectations of privacy and professionalism in the online realm. These conversations will help shape guidelines to maintain quality and propriety in the increasingly virtual doctor’s office. Such discussions and investigations of current use will also inform the necessary legal scholarship that will develop around online social networks so health care providers may better understand their liability for online communication. Answering these ethical questions alongside the practical questions of health outcomes and provider and patient satisfaction will support increasing appropriate use of online social networks in health care delivery.

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